Provider Demographics
NPI:1023308350
Name:WATANABE, IAN LANE (MFT)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:LANE
Last Name:WATANABE
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 VANCOUVER PL
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96822-2453
Mailing Address - Country:US
Mailing Address - Phone:808-371-6321
Mailing Address - Fax:
Practice Address - Street 1:1827 VANCOUVER PL
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96822-2453
Practice Address - Country:US
Practice Address - Phone:808-371-6321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMFT 242106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist